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Round on Systems.

8 April 2014

Behold! Two posts on health care delivery in a row! This morning I was meeting with the leadership of our cardiac surgery center for a project I’m working on. We’re upending the schedules of our surgeons and cardiologists in order to improve our service thresholds, and it looks like there’s going to be a lot of positive impact. I’m excited. That’s what gets me out of bed in the morning as a health care engineer: personal glo… I mean making a difference in the lives of our patients.

While having that discussion, we were also discussing the next phase of our analysis, which will likely be to examine the effects of different types of discharge strategies. Every hospital in the world, I’d wager, struggles with discharge processes. There are a lot of things that have to happen, in a particular order, at particular times. All while ensuring that the patient is well cared-for and doesn’t have status changes during the process. It’s complicated. It can seem like, the night before when discussing which patients should be ready to leave the next day, the actual discharges are totally unrelated to the predicted discharges.

And I had a simple idea, that our leadership liked: round on systems. Just like MDs round on patients, we need to round on the systems. For each of those predicted discharges, the next day, when patients either have or have not been discharged, we should review how the discharge process went: why were they, why weren’t they, which ones went smoothly, which ones didn’t? Who was discharged early in the day, who was discharged late? Don’t just take the data and look for predictors and covariates of discharge. Talk about the systems.

We recently had a briefing in which we discussed how US Navy aircraft carriers operate. They’re about the most complex system in the world: a warship, an airport, a hospital, a nuclear reactor, and a massive living and feeding quarters. They’re operated almost entirely by very young sailors. And they have a stellar safety record, considering they are towing around enough dangerous material to vaporize the Eastern Seaboard. How do they do it? They round on systems. Every carrier landing is given a post-mortem discussion by the pilot, other pilots, and air traffic controllers, flight crew. They talk about what went right, what went wrong. Every person understands the system, and their role in it.

There is no reason that health care delivery can’t do this. We should embed systems thinking into the process of patient care, either by training some of the MDs and RNs in it, or by including systems personnel in the rounding. Talk about the systems. Learn from experience what went right and what went wrong. Share the insights. Every patient admission, discharge, and bed move should be discussed as part of the rounding process. Why did it work, what could have been done better? Until you can land a fighter jet on the ICU. Or some metaphor that makes sense.

We can do better with delivery systems. We have to. Because bad systems engineering (or even worse, no systems engineering) is inimical to the mission of hospitals, providers, and the human endeavor of medicine generally.

4 Comments leave one →
  1. 8 April 2014 11:56

    This is a really interesting question about Navy carriers and their safety record. Perhaps it’s that young sailors are trained and trained and trained and drilled and trained on their procedures? It would be interesting to know if any other fields (science/medicine, especially) would be willing to sacrifice that level of autonomy.

    • 8 April 2014 12:13

      That’s almost certainly part of it. But the perspective that in the military you can just order people to do stuff and they do it is absolutely false. It has the same bureaucratic BS and worse as everywhere.

    • 8 April 2014 12:14

      Not that I think you are necessarily espousing that perspective. But many people think, “Of course the military can do it, they just issue orders!” Doesn’t work that way.

  2. 8 April 2014 12:28

    I don’t see why systems can’t be both imbedded via training of HCPs and with systems professionals as part of the team. MDs and RNs are already trained to follow protocols in health care delivery. I believe that a delivery systems assessment could easily become part of the set of normal protocols, especially if training is started with new students. Having a specialized health care systems professional as part of the team would serve to keep the assessments on track and updated with best procedures. Been through two discharges in past year and have seen how un-systematic they can be.

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